QUESTION: In patients presenting with acute bronchitis, does verbal advice plus an information leaflet describing the
uncertain value of antibiotics for this condition reduce antibiotic use more than verbal advice alone?

Setting

Patients

259 consecutive adults ≥16 years of age presenting with acute bronchitis, defined as a new acute lower respiratory tract illness
(ie, illness for ≤21 d; main symptom of cough; ≥1 symptom of sputum production, dyspnoea, wheeze, or chest discomfort or pain;
and no alternative explanation), who were not under medical supervision for an underlying disease such as asthma, chronic
obstructive pulmonary disease, heart disease, or diabetes. 47 patients were judged to need antibiotics immediately. 212 patients
were judged to not need antibiotics immediately and were subsequently randomised (median age 44–45 y, 58% women). 205 of these
patients (97%) were included in the analysis.

Intervention

All patients received a prescription for antibiotics. 106 patients were allocated to verbal advice from the general practitioner
plus an information leaflet. Verbal advice was based on a prompt card: “I have examined you and I am happy there is no sign of serious disease which definitely needs antibiotics today. Most chesty
illnesses get better on their own, although the cough may take a long time to go completely. Antibiotics don't seem to make
much difference to how quickly most people recover. However, if you feel you are getting worse after a while, considering
taking antibiotics then would be reasonable. So, here is a prescription for an antibiotic for you to keep at home. You are
quite likely not to need it, but use your judgment whether to get them in due course.” The information leaflet described the natural course of lower respiratory tract symptoms and the advantages and disadvantages
of antibiotic use. 106 patients were allocated to verbal advice alone.

Main outcome measures

Main results

Fewer patients who received verbal advice plus the information leaflet took their antibiotics than did patients who received
verbal advice alone (table). The groups did not differ for reconsultation rates at 4 weeks {11% v 13%, p=0.54}.*

COMMENTARY

Georgetown University - School of Nursing and Health Studies Washington, DC, USA

Although the ineffectiveness of antibiotics in the treatment of acute bronchitis is well documented,1 antibiotic prescribing rates remain high.2 Diagnostic uncertainty, patient expectations, and patient satisfaction are factors that have been identified as contributing
to the continued use of antibiotics.2

Studies have examined the effects of educating practitioners and patients about antibiotic use. Patient education has the
potential to reduce antibiotic use while maintaining patient satisfaction. The study by Macfarlane et al compared the effectiveness of verbal advice alone versus verbal advice plus written patient education. The study was well
designed and showed that verbal advice plus written instructions reduced antibiotic use. Based on the number needed to treat
(NNT), 7 patients would need to receive verbal advice plus written patient education to reduce unnecessary antibiotic use
in 1 additional patient.

MacFarlane et al added the variable of patient autonomy to this study, allowing patients to make the ultimate decision about antibiotic use.
Placing this decision in patients' hands could potentially increase or decrease antibiotic use. Empowerment is likely to increase
patient satisfaction, and patients who feel empowered may consider their choices more carefully. Alternately, the fact that
the prescription was given may suggest to them that antibiotics will likely be required. The only criterion patients were
given for taking antibiotics was that the illness or cough was “getting worse”, providing little assistance in decision making.

Further study is needed to resolve the prognostic uncertainty of prolonged symptoms and provide clearer guidelines about who
ultimately needs antibiotics.3 In addition, more study of the influence of patient autonomy would clarify how this variable affects patient decision making.